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PubMed1991

A randomised trial comparing endometrial resection and abdominal hysterectomy for the treatment of menorrhagia.

OBJECTIVE: To determine the advantages and disadvantages of endometrial resection and abdominal hysterectomy for the surgical treatment of women with menorrhagia. DESIGN: Randomised study of two treatment groups with a minimum follow up of nine months. SETTING: Royal Berkshire Hospital, Reading. SUBJECTS: 51 of 78 menorrhagic women without pelvic pathology who were on the waiting list for abdominal hysterectomy. TREATMENT: Endometrial resection or abdominal hysterectomy (according to randomisation). Endometrial resections were performed by an experienced hysteroscopic surgeon; hysterectomies were performed by two other gynaecological surgeons. MAIN OUTCOME MEASURES: Length of operating time, hospitalisation, recovery; cost of surgery; short term results of endometrial resection. RESULTS: Operating time was shorter for endometrial resection (median 30 (range 20-47) minutes) than for hysterectomy (50 (39-74) minutes). The hospital stay for endometrial resection (median 1 (range 1-3) days) was less than for hysterectomy (7 (5-12) days). Recovery after endometrial resection (median 16 (range 5-62) days) was shorter than after hysterectomy (58 (11-125) days). The cost was 407 pounds for endometrial resection and 1270 pounds for abdominal hysterectomy. Four women (16%) who did not have an acceptable improvement in symptoms after endometrial resection had repeat resections. No woman has required hysterectomy during a mean follow up of one year. CONCLUSION: For women with menorrhagia who have no pelvic pathology endometrial resection is a useful alternative to abdominal hysterectomy, with many short term benefits. Larger numbers and a longer follow up are needed to estimate the incidence of complications and the long term efficacy of endometrial resection.

Adult↗
PubMed2001

Laparoscopic versus open bowel resection for Crohn's disease.

BACKGROUND: Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn's disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn's disease compared with the open technique in a tertiary Canadian centre. PATIENTS AND METHODS: A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn's disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months). RESULTS: Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free interval was the same length for both groups (23.9+/-17.3 months for the laparoscopic resection patients compared with 23.9+/-20.2 months for the open resection patients; P=1.00). CONCLUSIONS: Laparoscopic resection for Crohn's disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted.

Adolescent↗
PubMedDate not supplied

Extended resections of ductal pancreatic cancer--impact on operative risk and prognosis.

114 patients received a standard and 75 patients an extended resection of ductal pancreatic carcinoma at the Hanover Medical School, Germany, from 1971 until 1993. Standard pancreatic resections were combined with vascular resection and reconstruction in 46 and additional organ resections in 45 cases. Vascular resections affected the mesentericoportal vein in 37, the common hepatic in 10 and the superior mesenteric artery in 7 cases. Pancreas resections were combined with total gastrectomy in 23, partial colectomy in 17, hemihepatectomy in 14, adrenalectomy in 8 and nephrectomy in 5 patients. Curative resections could be accomplished in 86% of patients without and 81% with extended resections. Additional vascular resections neither increased the operative risk nor deteriorated the long-term prognosis after resection. Additional organ resections, however, significantly increased the risk of lethality and impaired the long-term prognosis. Especially resections of synchronous hepatic metastases and colectomies were associated with a poor survival probability.

Carcinoma↗
PubMedDate not supplied

Harry M. Vars award. The effect of a pectin-supplemented elemental diet on intestinal adaptation to massive small bowel resection.

The effect of a pectin-supplemented elemental diet on intestinal adaptation to massive small bowel resection in the rat was investigated in this study. Sixty adult Sprague-Dawley rats underwent placement of a feeding gastrostomy and swivel apparatus. Control animals (N = 16) were then returned to their cages while the remaining animals underwent an 80% small bowel resection and anastomosis (resected, N = 44). Postoperatively, animals were randomly assigned to receive either a fat- and fiber-free elemental diet (no pectin) or the same diet supplemented with 2% pectin (pectin). After 8 days of full strength diet, samples of jejunum, ileum, and colon were obtained for analysis. The weights per unit length of the ileum and colon were significantly greater in the resected pectin group than either the resected no pectin or pectin control groups. Mucosal parameters (unit weight, DNA, RNA, and protein content) were significantly increased in the jejunum and ileum of both the resected pectin and resected no pectin groups relative to their respective control groups. However, jejunal and ileal mucosal parameters were significantly greater (1.3- to 2-fold) for the resected pectin group than for the resected no pectin group. All the mucosal parameters of the colons were significantly greater for the pectin resected group than for the pectin control group, while only colonic mucosal RNA was significantly greater for the no pectin resected group than for the no pectin control group. These data indicate that the addition of pectin to an elemental diet significantly enhanced intestinal adaptation to massive small bowel resection in the rat.

Adaptation, Physiological↗
PubMed1987

Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas.

Thirty-one patients operated upon for supratentorial glioblastomas or anaplastic astrocytomas were studied to evaluate the effect of the extent of surgical resection on the length and quality of survival. The median age was 50 years and the median preoperative Karnofsky rate was 80. Twenty-one patients (68%) had glioblastoma multiforme, and 10 patients (32%) had anaplastic astrocytoma. Early postoperative enhanced computed tomography was used to determine the extent of tumor resection. Gross total tumor resection was accomplished in 19 patients (61%), and subtotal resection was performed in 12 patients (39%). The two groups were comparable regarding age, sex, pathological condition, preoperative Karnofsky rating, tumor location, postoperative radiation therapy, and postoperative chemotherapy (P greater than 0.05). The gross total resection group lived longer than the subtotal resection group by life table analysis (P less than 0.001; median survival of 90 and 43 weeks, respectively). Postoperatively, the mean functional ability measured by the Karnofsky rating was significantly increased in the gross total resection group (P = 0.006), but not in the subtotal resection group (P greater than 0.05). The difference in degree of change between preoperative and postoperative Karnofsky rating in the two groups was statistically significant (P = 0.002). The gross total resection group spent significantly more time after the operation in an independent status (Karnofsky rating greater than or equal to 80) compared to the subtotal resection group (P = 0.007; median time of 185 and 12.5 weeks, respectively). Gross total resection of supratentorial glioblastomas and anaplastic astrocytomas is feasible and is directly associated with longer and better survival when compared to subtotal resection.

Adult↗
PubMed2001

Surgical resection of intrinsic insular tumors: complication avoidance.

OBJECT: Surgical resection of tumors located in the insular region is challenging for neurosurgeons, and few have published their surgical results. The authors report their experience with intrinsic tumors of the insula, with an emphasis on an objective determination of the extent of resection and neurological complications and on an analysis of the anatomical characteristics that can lead to suboptimal outcomes. METHODS: Twenty-two patients who underwent surgical resection of intrinsic insular tumors were retrospectively identified. Eight tumors (36%) were purely insular, eight (36%) extended into the temporal pole, and six (27%) extended into the frontal operculum. A transsylvian surgical approach, combined with a frontal opercular resection or temporal lobectomy when necessary, was used in all cases. Five of 13 patients with tumors located in the dominant hemisphere underwent craniotomies while awake. The extent of tumor resection was determined using volumetric analyses. In 10 patients, more than 90% of the tumor was resected; in six patients, 75 to 90% was resected; and in six patients, less than 75% was resected. No patient died within 30 days after surgery. During the immediate postoperative period, the neurological conditions of 14 patients (64%) either improved or were unchanged, and in eight patients (36%) they worsened. Deficits included either motor or speech dysfunction. At the 3-month follow-up examination, only two patients (9%) displayed permanent deficits. Speech and motor dysfunction appeared to result most often from excessive opercular retraction and manipulation of the middle cerebral artery (MCA), interruption of the lateral lenticulostriate arteries (LLAs), interruption of the long perforating vessels of the second segment of the MCA (M2), or violation of the corona radiata at the superior aspect of the tumor. Specific methods used to avoid complications included widely splitting the sylvian fissure and identifying the bases of the periinsular sulci to define the superior and inferior resection planes, identifying early the most lateral LLA to define the medial resection plane, dissecting the MCA before tumor resection, removing the tumor subpially with preservation of all large perforating arteries arising from posterior M2 branches, and performing craniotomy with brain stimulation while the patient was awake. CONCLUSIONS: A good understanding of the surgical anatomy and an awareness of potential pitfalls can help reduce neurological complications and maximize surgical resection of insular tumors.

Adult↗
PubMedDate not supplied

Study on endoscopic esophageal mucosal resection with ligating device. II--Experimental study.

BACKGROUND/AIMS: This study reports on animal experiments regarding the safety of endoscopic esophageal mucosal resection with a ligating device (EEMRL), as well as the amount of mucosa which can be removed by this technique, the depth of resection and the feasibility of piecemeal resection. METHODOLOGY: Three experiments were performed in six mongrel dogs under general anesthesia. RESULTS: When EEMRL was done without submucosal injection of saline, resection reached the muscular layer and caused esophageal perforation. The average dimensions of the mucosal pieces resected using 8-, 10-, and 12-mm devices was 13 x 10 mm, 18 x 15 mm, and 22 x 18 mm, respectively. Resection reached the mid-plane of the submucosa and the depth was almost uniform. After piecemeal resection, there was no macroscopically visible mucosa at the resection site and each mucosal piece was resected along the mid-plane of the submucosa. CONCLUSIONS: The experimental study indicated that submucosal injection of saline is essential to prevent esophageal perforation. It also showed that EEMRL allows resection up to the mid-plane of the submucosa, that the 12-mm device allows en bloc resection of lesions < or = 15 mm in diameter and that EEMRL is suitable for piecemeal resection.

Animals↗
PubMed2001

[Combined portal vein and liver resection for biliary cancer].

Portal vein resection has become common in hepatobiliary resection for biliary cancer with curative intent. When cancer invasion of the portal vein is very limited, wedge resection followed by transverse closure is indicated. Longitudinal closure is contraindicated, as this procedure causes stenosis of the portal vein. In the case of right hepatectomy, segmental resection is feasible before liver transection. Reconstruction is completed with end-to-end anastomosis, in which an intraluminal technique is used for posterior anastomosis and an over-and-over suture for anterior anastomosis. More than 5-cm resection of the portal vein often requires reconstruction with an autovein graft. In the case of left hepatectomy, portal vein resection after liver transection is preferable. The resection and reconstruction method should be determined based on both the extent of cancer invasion of the right portal vein and the length of the right portal trunk. So far, we have aggressively carried out combined portal vein and liver resection in 106 patients with advanced biliary cancer (62 cholangiocarcinoma and 44 gallbladder carcinoma). Twenty-nine patients underwent wedge resections and 77 segmental resections (66 end-to-end anastomosis and 11 autovein grafting using an external iliac vein). In patients with hilar cholangiocarcinoma (n = 58), 3- and 5-year survival rates were 23% and 8%, respectively. Three patients survived for more than 5 years after resection. In contrast, the prognosis of patients with gallbladder cancer (n = 44) was dismal. All of the patients died within 3 years after surgery, although they survived statistically longer than unresected patients. These data suggest that portal vein resection has survival benefit for patients with cholangiocarcinoma. However, the indications for this procedure in gallbladder cancer should be reevaluated.

Biliary Tract Neoplasms↗
PubMed2002

Resectable gastric cancer: operative mortality and survival analysis.

BACKGROUND: This study evaluated the survival outcome and determined the prognostic factors for gastric cancer patients who underwent gastric resection in the past 6 years. METHODS: Between 1994 and 2000, a total of 1,322 patients with gastric cancer who underwent gastric resection in our hospital comprised the study subjects. Their mean age was 61.1 (range, 14-92) years. There were 865 male and 457 female patients. Total gastrectomy was performed in 389 (29.4%) and distal gastrectomy in 933 patients. Curative resection was performed in 961, and palliative resection in 361 patients. A D2 or greater lymphadenectomy was required for curative resection. Patients received postoperative chemotherapy if they underwent palliative resection. RESULTS: Early or pT1 gastric cancer accounted for 17.7% and lymph node metastasis for 62.1% of all resected cases. The overall operative mortality and morbidity rates were 3.3% and 18.0%, respectively. The operative mortality for palliative total gastrectomy was particularly high (8.5%). The overall cumulative 5-year survival rate of all resected patients was 45.6%, and it was 57.0% after curative resection. Multivariate analysis revealed that lymph node metastasis, serosal invasion, peritoneal seeding, positive resection margin, liver metastasis, old age, tumor size, and lymphatic invasion were independent prognostic factors. CONCLUSION: The most important prognostic factors for survival were lymph node metastasis, serosal invasion, peritoneal seeding, positive resection margin, liver metastasis, old age, tumor size, and lymphatic invasion. The operative mortality and survival outcome of our gastric cancer patients after gastric resection compared favorably with those of other series in other countries.

Adolescent↗
PubMed1989

[Primary cytoreductive surgery of advanced ovarian cancer with special reference to the significance of bowel resection].

The importance of cf cytoreductive surgery is discussed with special reference to the bowel resection for advanced epithelial ovarian cancer. In the 10.5-year period from January 1978 to June 1988, 134 patients with epithelial ovarian cancer were seen at Toranomon Hospital. Two (15%) out of 13 patients with epithelial ovarian cancer at stage II underwent bowel resection to achieve cytoreduction, 10 (31%) out of 32 at stage III, and 4 (36%) out of 11 at stage IV, respectively. Modified posterior pelvic exenteration was the most common operative procedure among the bowel resections. In this procedure, resection of both sigmoid colon and rectum and end-to-end anastomosis was carried out. Besides bowel resection, all patients at stage II-IV had abdominal hysterectomy, and bilateral salpingo-oophorectomy with or without omentectomy. Comparison of the treatment was by the method of Kaplan-Meier and the Wilcoxon test. The following results were obtained. 1) Five-year survival rate for patients with bowel resection was 60%, compared to 39% for those undergoing operation without bowel resection (p less than 0.05). 2) Two-year survival for patients having residual cancer even after bowel resection was 61%, compared to 28% for those with residual cancer without bowel resection (p less than 0.05). 3) Two-year survival for patients with residual cancer greater than 2 cm was 8%, compared to 62% for those with residual cancer less than 1.9 cm (p less than 0.05). 4) Four patients who died of cancer 15-26 months after the initial treatment including bowel resection spent 65-85% (mean 76%) of the survival period with normal or subnormal activity, against 0-85% (mean 30%) for 6 patients without bowel resection and with the matched survival period of 15-26 months. Also, the former spent 19-33% (mean 27%) of their survival period in the hospital, against 20-67% (mean 39%) by the latter. These results suggest that bowel resection should be encouraged in order to achieve optimal cytoreduction in patients with advanced epithelial ovarian cancer because of its effectiveness in prolonging survival and the inherent benefits for quality of life.

Fallopian Tubes↗
PubMed1993

Synchronous, metachronous, and multiple hepatic resections of liver tumors originating from primary gastric tumors.

BACKGROUND: The role of hepatic resection for noncolorectal gastrointestinal malignancies involving the liver is not well defined. To address this issue we studied our experience with resection of liver tumors arising from primary gastric malignancies. METHODS: A retrospective study of 195 patients who underwent a total of 207 liver resections identified 12 patients with primary gastric cancer who underwent 16 resections for liver involvement. There were 10 adenocarcinomas and two leiomyosarcomas. We examined the type of hepatic surgery, the status of residual disease, and the primary histologic findings. Morbidity, mortality, and actual survival rates were recorded. RESULTS: Thirty-day operative mortality was 8.3% (1 of 12). Hospital mortality was 25% (3 of 12). Operative morbidity occurred in three of nine survivors (33%). Synchronous en bloc resection (n = 3) of stomach and liver for adenocarcinoma produced two long-term survivors (no evidence of disease for 10 and 13 years). Mean survival after synchronous discontinuous resection (n = 4) was 8 months (range, 2 to 17 months). Metachronous resection for adenocarcinoma (n = 3) produced one long-term survivor (74 months), and one patient with recurrent leiomyosarcoma underwent a total of five liver resections and survived 64 months. CONCLUSIONS: For adenocarcinoma, en bloc resection of contiguous liver involvement produced long-term survivors. Synchronous resection of discontinuous metastases did not. Metachronous resection of isolated disease and multiple resections of recurrent isolated disease may have value in carefully selected patients.

Adenocarcinoma↗
PubMedDate not supplied

Segmental liver resections for hilar cholangiocarcinoma.

BACKGROUNDS/AIMS: Liver resection for hilar cholangiocarcinoma is now popular, and combined en bloc resection of the caudate lobe has become general practice, especially in Japan and some European countries. However, surgical procedure is not yet standardized, and many problems concerning surgical treatment of this disease still remain unsolved. METHODOLOGY: From April 1977 to December 1996, 173 patients with hilar cholangiocarcinoma were treated at The First Department of Surgery, Nagoya University Hospital. Of the 173 patients, 138 patients underwent surgical resection, including 124 liver resections and 14 bile duct resections. RESULTS: Several kinds of hepatic segmentectomy with en bloc resection of the caudate lobe were performed in the 124 patients: 109 underwent hepatic lobectomy or more extensive resection including central bisegmentectomy; 15 received resection of one or less segment of the liver. Aggressive resections, including combined portal vein and liver resection (n = 41) and hepatopan-creatoduodenectomy (n = 16), were applied to advanced hilar cholangiocarcinoma. The hospital death rate in hepatectomized patients was 9.7% (12/124). The 3- and 5-year rates for the 97 patients with curative hepatectomy were 42.7%, and 25.8%, respectively. CONCLUSIONS: Aggressive liver resection improves survival of patients with hilar cholangiocarcinoma. Resection procedures should be designed based on a precise diagnosis of the extent of carcinoma.

Bile Duct Neoplasms↗
PubMed1998

Comparison of liver function tests after hepatic lobectomy and hepatic wedge resection.

Prior studies have suggested that changes in liver function tests may vary with the postoperative time interval and may be related to the extent of hepatic resection. This study describes characteristic profiles in parenchymal liver enzymes and other serum liver function tests over a 4-week course comparing anatomic to nonanatomic hepatic resections. The records of 48 patients undergoing successful major hepatic resection during a 3-year period were retrospectively reviewed. Of these 48 patients, 28 underwent formal anatomic resection (hepatic lobectomy), and 20 underwent nonanatomic resections (wedge resection). Routine postoperative management in lobectomy patients included drawing liver function tests and enzymes daily for the first week, then at approximately 2 and 4 weeks postoperatively. These tests included: prothrombin time (PT), partial thromboplastin time, total serum bilirubin, total protein (TP), aspartate transaminase, lactate dehydrogenase (LDH), alkaline phosphatase, albumin (A), and glucose. Patients undergoing wedge resections had these values checked less frequently, approximately 3 to 5 days, 2 weeks, and 4 weeks postoperatively. Profiles of these values were plotted over the 4-week postoperative time course for each group of patients. Patients undergoing hepatic lobectomy showed a characteristic laboratory value profile. PT elevated within 48 hours to a mean high of 16.0 seconds, then returned to normal by postoperative day 4. Partial thromboplastin time levels remained normal throughout the entire perioperative course. Total bilirubin rose slightly, to a mean high of 2.6 mg/100 cc, then returned to normal by postoperative day (POD) 14. Parenchymal liver enzymes aspartate transaminase and LDH rose abruptly to very high levels, then returned abruptly to normal (by POD 5). TP and A both fell to approximately 50 per cent of normal, gradually rising to normal by POD 14. Glucose rose to a mean high of 199 mg/100 cc within the first 5 days, then returned to normal by POD 7. Alkaline phosphatase remained normal initially, then showed a progressive rise to a high of 288 mg/100 cc on POD 14. Patients undergoing wedge resections did not show the same changes in total serum bilirubin, but showed similar trends in all other tests, although the magnitude of these changes was smaller. TP and A levels fell acutely after resection, then began a slow rise toward normal by POD 21. TP and A profiles were similar for both lobectomy patients and those undergoing wedge resection. The only tests that may have altered clinical management were the PT and total bilirubin. Patients undergoing major hepatic resection have characteristic postoperative profiles of liver enzymes and liver function tests. These laboratory profiles differ with the extent of hepatic resection. The profiles reflect changes in volume status, parenchymal liver destruction, transient hepatic insufficiency, and postoperative hepatic regeneration. However, except possibly for PT and bilirubin, the routine use of these tests is not recommended, given that the results do not alter clinical management.

Follow-Up Studies↗
PubMed2001

Cricotracheal resection in children.

OBJECTIVE: To review our experience with cricotracheal resection in a pediatric population. DESIGN: Prospective case review of a cohort of patients undergoing cricotracheal resection. SETTING: Tertiary care pediatric hospital. PATIENTS: Forty-four consecutive patients undergoing cricotracheal resection between January 1, 1993, and December 31, 1998. MAIN OUTCOME MEASURES: Decannulation rates. RESULTS: Thirty-eight (86%) of the 44 children are decannulated. The ultimate decannulation rate was independent of the presenting grade of subglottic stenosis. Fourteen children (100%) had a primary cricotracheal resection; all are decannulated. Twenty-one children had a salvage cricotracheal resection, and 19 (90%) are decannulated. Nine children had an extended cricotracheal resection, of whom 5 (56%) are decannulated. A primary cricotracheal resection was performed on a child on whom no previous open airway procedure had been performed. A salvage cricotracheal resection was performed on a child on whom previous open airway reconstruction had not resulted in an adequate airway. An extended cricotracheal resection was performed on a child on whom the cricotracheal resection was combined with a second procedure, either additional expansion cartilage grafting or an open arytenoid procedure. Most of these children had complex airway pathologic conditions. CONCLUSION: Cricotracheal resection complements standard laryngotracheal reconstruction techniques in a pediatric population.

Adolescent↗
PubMed2002

Combination of neoadjuvant chemotherapy with cryotherapy and surgical resection for the treatment of unresectable liver metastases from colorectal carcinoma.

BACKGROUND: This retrospective study was conducted to assess the safety, efficacy, and long-term results of neoadjuvant chemotherapy and cryotherapy as additional means for eradicating liver metastases from colorectal carcinoma when curative treatment was not possible by resection alone. METHODS: Between January 1996 and December 1997, 131 patients with unresectable liver metastases were referred to our department and received chemotherapy. After 3-6 months of chemotherapy, curative surgery of liver metastases was considered possible in 57 patients, either by resection alone in 33 patients (25%) or cryotherapy associated with resection in 24 patients (18%). Characteristics and survival of patients in the cryotherapy plus resection group were compared with those of the 33 patients in the resection group. RESULTS: All patients in the resection group had partial response to neoadjuvant chemotherapy. In the cryotherapy plus resection group, neoadjuvant chemotherapy resulted in 13 partial responses, 9 stable diseases, and 2 disease progressions. The rate of postoperative complications in the entire series was 14%. No major difference was seen between the two groups. After a median follow-up of 48 months, the median survival time was 39 months. The survival rates at 1, 3, and 4 years were similar in both groups: 94, 58, and 37% in the resection group and 92, 50, and 36% in the cryotherapy plus resection group, respectively. CONCLUSIONS: The combination of neoadjuvant chemotherapy, cryotherapy, and liver resection constitutes a promising treatment strategy for patients with extremely advanced metastatic liver involvement. Patients having more than four liver metastases from a colorectal carcinoma or patients with a poor liver reserve due to previous resection should be screened carefully to determine whether they could be candidates for this procedure.

Adult↗
PubMedDate not supplied

Extended resection for higher-stage non-small-cell lung cancer.

This report reviews the results of extended surgical resection for advanced lung cancer (stage IIIa, IIIb, IV) reported in the Anglo-American literature between 1980 and 1993. Complete resection of stage IIIa (T3) tumors with minimal or no nodal involvement resulted in a 5-year survival approaching 40%. Ipsilateral mediastinal nodal involvement (N2) lowered 5-year survival to 10-15% and to near 0% if bulky disease was present. Historically, resection of stage IIIb disease has failed to improve survival. Radiation therapy has decreased local recurrence in advanced-stage disease but has not improved survival. Preliminary results have recently been reported using induction chemotherapy or chemoradiotherapy followed by resection in subsets of patients with stage IIIa and IIIb disease. Induction chemotherapy for bulky N2 (IIIa) disease resulted in major response rates of up to 77% and a 5-year survival of up to 26% after complete resection. Preliminary results of resection of stage IIIb tumors following induction chemotherapy have achieved 2-year survivals of 40%. Metastatic lung cancer (stage IV) with disseminated disease remains virtually incurable with poor response rates to chemotherapy. However, resection of isolated brain metastases (M1 disease) resulted in a 5-year survival near 25%. Resection of other sites of isolated metastatic disease including the adrenal gland is under investigation. The major prognostic factor in these studies has been the ability to completely resect all tumor. To improve resectability rates, induction therapy and radical resections are being combined more frequently. The increased morbidity and mortality of these aggressive approaches requires careful patient selection.

Carcinoma, Non-Small-Cell Lung↗
PubMed1997

Hartmann's procedure vs. abdominoperineal resection for palliation of advanced low rectal cancer.

UNLABELLED: In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmann's procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmann's procedure vs. abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4-8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6 +/- 10.3 years) had Hartmann's procedure, and 26 patients (12 females; mean age, 68.8 +/- 8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (+/-17.5) and 18.6 months (+/-12.9) in Hartmann's procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4 +/- 26.7 minutes for Hartmann's procedure group and 124.6 +/- 27.1 minutes for the abdominoperineal resection group (P > 0.05; not significant). Postoperatively, Hartmann's procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmann's procedure group was ambulant after a mean of 2.4 days vs. a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmann's procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmann's procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmann's procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.

Abdomen↗
PubMed1996

Better preservation of immune function after laparoscopic-assisted vs. open bowel resection in a murine model.

UNLABELLED: We evaluated cell-mediated immune function after laparoscopic-assisted and open bowel resection in rats by measuring delayed-type hypersensitivity responses to keyhole limpet hemocyanin (KLH) and phytohemagglutinin (PHA). METHODS: Male Sprague-Dawley rats (n = 120) were sensitized to 1 mg of KLH ten days before investigations. Rats were challenged preoperatively, immediately postoperatively, and on postoperative day (POD) 2 with an intradermal injection of 0.3 mg of KLH and 0.2 mg of PHA (at different sites). Averages of two measures of perpendicular diameters (taken 24 and 48 hours postchallenge) were used to calculate the area of induration using the formula for the area of an ellipse, A = (D1/2 x D2/2) x pi. Anesthesia control animals underwent no procedure (n = 40). Open resection group underwent ligation and resection of the cecum (length = 2 cm) through a 7 cm midline incision (n = 40). In the laparoscopic-assisted resection group, under CO2 pneumoperitoneum (4-6 mmHg), the cecum was identified, dissected free, and exteriorized through a 4 mm port. The cecum was then ligated and resected extracorporeally (n = 40). RESULTS: Preoperative responses to both KLH and PHA were the same in all three groups. Furthermore, within each group, postoperative responses were similar. When groups were compared, the anesthesia group responses were significantly greater than the open resection group responses at all time points (P < 0.05 for all comparisons). Laparoscopic assisted resection group responses differed from control at only two of eight postoperative measures. Laparoscopic resection group responses were significantly greater than open resection group responses to challenge with both KLH and PHA on POD1 (P < 0.02, for both comparisons) and POD 4 (P < 0.05, for both comparisons). CONCLUSIONS: Postoperative cell-mediated immune function is better preserved after laparoscopic-assisted bowel resection than after open resection as assessed by skin antigen testing.

Animals↗